Sensors, Cables, and Disrupted Intimacy: Anthropological Explorations in the Sleep Lab

Sleep is a fragile state. It is easily disrupted and does not come at our bidding. For even though we can try to create ideal conditions for getting sufficient restful sleep, it cannot be consciously controlled. Because there is no intentional action by which we can will ourselves to sleep, sleep disorders are all the more distressing. Consequently, getting to the bottom of the various types and causes of disturbed sleep has long been an important concern in medicine and related fields. Today, this is often studied with the help of sleep labs. But do they actually work? We talked with Julia Vorhölter about her research in German sleep labs and about the particular atmosphere of a space where the private and intimate realm of sleep meets technological diagnostic equipment.

Julia, how did you decide to study insomnia?
There were four main things, I think, that led me to turn my attention to this topic. To start with, there was a period in my life when I had my own struggles with sleeplessness. This was in many ways quite an existential and exhausting experience, but also an intriguing one. During this time, I was also looking for a new research topic and I discovered that while there was substantial anthropological research on the topics of dreams and dreaming, there was very little about sleep and sleeplessness. A third consideration was the fact that mobility was greatly limited at the time because of the COVID pandemic. So I needed a research topic that I could pursue from home, without having to travel. And lastly, I was able to gain access to different sleep labs, where I carried out most of my field research for this project.

Sleep fundamentally shapes the organization of social life

What makes this topic so anthropologically interesting?
There are many reasons. To start with, the fact that it is biologically necessary for us to spend about a third of our lives sleeping in order to maintain our health and well-being has interesting implications from a social science perspective. Sleep or the lack thereof is a ubiquitous topic in everyday conversations and in the media. And sleep – when, where, and how people sleep and are allowed to sleep – fundamentally shapes the organization of social life.

If the need for sleep is universal, does that mean sleep is the same everywhere?
Although we all require sleep, sleeping habits are very diverse and often shaped by external circumstances such as one’s socioeconomic situation. Thus, sleep is a social phenomenon that can allow us to draw conclusions about class relations, traditions, and social values.

Can you give an example?
Ideas about sleep play a major role in child-rearing practices. While the specifics vary depending on the social context, most societies have well-established and often quite rigid expectations about when children should sleep, for how long, and where – whether they should go to sleep alone in their own room or share a bed with parents and siblings. And deviations from the norm can result in highly emotional contestations.

Why do you think there has been so little anthropological research on sleep and sleeplessness?
Sleep and sleeplessness are very subjective, private, and intimate. This makes it very difficult to observe. People talk a lot about sleep, particularly when they feel that they sleep poorly. But sleep is not something that we can really experience consciously, and therefore it can only be expressed narratively to a limited degree. Often there is an enormous disjunct between our own perception of sleep and sleep as it is measured and recorded, for example, in sleep labs or by sleep apps. But both ways of understanding sleep are important.

Why sleep labs? What makes them interesting for an anthropology of sleep?
A sleep lab is one of the few places where people allow themselves to be observed during sleep and where subjective perception and objective measurement of sleep converge. People come there because they feel like they are sleeping poorly. The goal of the sleep lab is to measure sleep in order to track down the causes of sleep disorders. I wanted to find out how this happens and whether it works.

And does it work? Can the diagnostic procedures of the sleep lab help sleepless patients?
In some cases, yes. There are good therapeutic options for people who suffer from sleep apnoea, a disorder in which the patient intermittently stops breathing during sleep. Although these episodes often go unnoticed by the sleeper, they can negatively affect the quality of sleep. With the help of CPAP masks, the obstruction of the airways that leads to these episodes can be prevented. However, the particular atmosphere of the sleep lab also creates problems that significantly influence the outcomes of sleep studies and our knowledge about sleep disorders.

The technical equipment in the lab impedes sleep

What sorts of problems?
The concept of the sleep lab disrupts not only the intimacy of human sleep, but also etiquette about how to treat people when they are asleep: people are woken up in order to reposition cables, they are watched with cameras while they sleep, and their behaviour during sleep is recorded and analysed with the help of countless instruments, some of which are attached to the sleeper’s body. This embeddedness in a technological environment significantly impedes sleep, the acquisition of knowledge about sleep, and the therapeutic treatment.

Do patients even manage to sleep at all under such conditions?
Some of them do, but for many people the situation in the sleep lab is stressful. In order to get enough data for valid results, six hours of sleep are ideally required. But as we all know, sleep isn’t something that we can simply summon and control at will. And of course, this is all the more difficult in the unfamiliar environment of a lab.

You mentioned that patients with sleep apnoea can often be treated successfully once they have been diagnosed in a sleep lab. But what about people who have trouble sleeping for other reasons?
Precisely this is another major problem. Sleep disorders that are not connected with apnoea are much more difficult to diagnose in the lab. The symptoms of apnoea – the frequency of episodes, changes in blood pressure and oxygen levels – are all measurable. They can be quantified and thus allow for an objective, evidence-based diagnosis. This, in turn, is important in the context of the current medical economy because it is a precondition for the coverage of costs by health insurance providers. Other types of sleep disorders require completely different diagnostic procedures that play a smaller role in the medical infrastructure compared to sleep labs.

Why is this the case?
The logic of the medical economy favours evidence-based diagnostics in a sleep lab. And in most labs these procedures are primarily focused on treating apnoea. But looking for the causes of other sleep disorders requires approaches that are not evidence-based in a narrow sense. For example, one of the most common sleep disorders, insomnia, is not defined so much by an objective lack of sleep or poor sleep quality, but by a fundamental discrepancy between the desired amount of sleep and the amount of sleep the patient is able to get. There is no easy way to measure this. Instead, diagnosis typically requires extensive anamnesis. Here data-based evidence plays only a minor role; what is important is the experience and empathy of the doctor during the consultations with the patient.

People who suffer from insomnia are often not taken seriously

So if the health-care system paid doctors better for patient consultations, sleep specialists wouldn’t focus so much on sleep apnoea but also treat other types of sleep disorders?
Yes, this is undoubtedly an important reason why the medical infrastructure for the treatment of apnoea in Germany is very different than the infrastructure for the treatment of insomnia – and a reason why people who suffer from chronic insomnia often have difficulty being taken seriously and finding help. Put simply: there is more money to be made in sleep labs than in patient consultations.

In order to describe the particular situation in a sleep lab, you developed three analytical concepts – “intimate space”, “techno-intimacies”, and “side affects”. What do these terms mean?
Medical personnel, patients, place, material, and meaning are interwoven at the sleep lab; these terms make it possible to describe the undesired effects that sometimes emerge from these encounters. The personal intimate space that is created during sleep is repeatedly disturbed by the personnel, who need to attach various devices to the patient and test that they are working. This often results in undesired intimate encounters and physical contact that are uncomfortable for everyone present. For the patients, this can then produce affective reactions that negatively influence their sleep, the data collected during monitoring, and, ultimately, the diagnosis. Drawing inspiration from the medical term “side effect”, which designates undesired effects of medication on the body, I chose the term “side affect” to refer to undesired responses of the body to diagnostic and therapeutic interventions.

When you talk about affects here, is this the same thing as emotions?
Following Brian Massumi’s work, I use “affect” to refer to a pre-conscious and pre-linguistic sensation. A reaction of the body to its environment. In the case of the sleep lab, I use it to describe how the human body reacts to the clinical atmosphere, even though the patients cannot immediately put into words what exactly they are reacting to and how. Emotions, by contrast, are culturally encoded interpretations of feelings, such as anger, sadness, fear. Affects are less definite, but they can similarly lead to a resonance or physical reaction that can scarcely be controlled.

The reactions in a sleep lab are uncontrollable?
I wouldn’t exactly say that, but they are certainly not always controllable to the degree that would be required for the diagnostic apparatus to get valid, evidence-based results.

What will you be working on next? Are you planning additional projects on the topic of sleep research?
I still have an article on the topic in the works, based on attending a number of sleep science congresses and industry exhibitions. I am interested in the interplay between science, research, clinical practice, and the pharmaceutical industry and how new treatment guidelines emerge from this.

Original publications
Julia Vorhölter 2023, Sleeping with Strangers – Techno-Intimacies and Side-Affects in a German Sleep Lab, Historical Social Research 48:2, 23-40.
doi: 10.12759/hsr.48.2023.14

Julia Vorhölter 2024, (Mis)Perceiving Apnea and Insomnia in Germany: A Tale of Two Disorders, Medical Anthropology, 43:1, 46-60.
doi: 10.1080/01459740.2023.2266858